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UNUM LIFE AND DISABILITY 401k Plan overview

Plan NameUNUM LIFE AND DISABILITY
Plan identification number 501

UNUM LIFE AND DISABILITY Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

XENIUM RESOURCES, INC has sponsored the creation of one or more 401k plans.

Company Name:XENIUM RESOURCES, INC
Employer identification number (EIN):931277996
NAIC Classification:561300

Additional information about XENIUM RESOURCES, INC

Jurisdiction of Incorporation: Oregon Secretary of State Corporations Division
Incorporation Date: 1999-10-01
Company Identification Number: 71378682
Legal Registered Office Address: 7401 SW WASHO CT #200

TUALATIN
United States of America (USA)
97062

More information about XENIUM RESOURCES, INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan UNUM LIFE AND DISABILITY

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01ANNE DONOVAN2023-08-17
5012021-01-01
5012020-01-01
5012019-01-01
5012018-01-01
5012017-01-01ANNE DONOVAN ANNE DONOVAN2018-09-16
5012016-01-01ANNE DONOVAN ANNE DONOVAN2017-10-11
5012015-01-01ANNE DONOVAN ANNE DONOVAN2016-10-17
5012014-01-01ANNE DONOVAN ANNE DONOVAN2015-08-25
5012013-01-01ANNE DONOVAN ANNE DONOVAN2014-10-02
5012012-01-01ANNE DONOVAN ANNE DONOVAN2013-09-12
5012011-01-01ANNE DONOVAN ANNE DONOVAN2012-07-27
5012010-01-01ANNE DONOVAN ANNE DONOVAN2011-08-17
5012009-01-01ANNE DONOVAN ANNE DONOVAN2010-07-28
5012009-01-01ANNE DONOVAN ANNE DONOVAN2010-07-28
5012009-01-01ANNE DONOVAN ANNE DONOVAN2010-07-15

Plan Statistics for UNUM LIFE AND DISABILITY

401k plan membership statisitcs for UNUM LIFE AND DISABILITY

Measure Date Value
2022: UNUM LIFE AND DISABILITY 2022 401k membership
Total participants, beginning-of-year2022-01-01565
Total number of active participants reported on line 7a of the Form 55002022-01-01624
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-01624
Number of employers contributing to the scheme2022-01-010
2021: UNUM LIFE AND DISABILITY 2021 401k membership
Total participants, beginning-of-year2021-01-011,320
Total number of active participants reported on line 7a of the Form 55002021-01-011,279
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-011,279
2020: UNUM LIFE AND DISABILITY 2020 401k membership
Total participants, beginning-of-year2020-01-011,420
Total number of active participants reported on line 7a of the Form 55002020-01-011,320
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-011,320
2019: UNUM LIFE AND DISABILITY 2019 401k membership
Total participants, beginning-of-year2019-01-011,512
Total number of active participants reported on line 7a of the Form 55002019-01-011,420
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-011,420
2018: UNUM LIFE AND DISABILITY 2018 401k membership
Total participants, beginning-of-year2018-01-011,070
Total number of active participants reported on line 7a of the Form 55002018-01-011,512
Number of retired or separated participants receiving benefits2018-01-010
Number of other retired or separated participants entitled to future benefits2018-01-010
Total of all active and inactive participants2018-01-011,512
2017: UNUM LIFE AND DISABILITY 2017 401k membership
Total participants, beginning-of-year2017-01-011,278
Total number of active participants reported on line 7a of the Form 55002017-01-011,070
Number of retired or separated participants receiving benefits2017-01-010
Number of other retired or separated participants entitled to future benefits2017-01-010
Total of all active and inactive participants2017-01-011,070
2016: UNUM LIFE AND DISABILITY 2016 401k membership
Total participants, beginning-of-year2016-01-011,746
Total number of active participants reported on line 7a of the Form 55002016-01-011,278
Number of retired or separated participants receiving benefits2016-01-010
Number of other retired or separated participants entitled to future benefits2016-01-010
Total of all active and inactive participants2016-01-011,278
2015: UNUM LIFE AND DISABILITY 2015 401k membership
Total participants, beginning-of-year2015-01-011,773
Total number of active participants reported on line 7a of the Form 55002015-01-011,746
Number of retired or separated participants receiving benefits2015-01-010
Number of other retired or separated participants entitled to future benefits2015-01-010
Total of all active and inactive participants2015-01-011,746
2014: UNUM LIFE AND DISABILITY 2014 401k membership
Total participants, beginning-of-year2014-01-011,958
Total number of active participants reported on line 7a of the Form 55002014-01-011,773
Number of retired or separated participants receiving benefits2014-01-010
Number of other retired or separated participants entitled to future benefits2014-01-010
Total of all active and inactive participants2014-01-011,773
2013: UNUM LIFE AND DISABILITY 2013 401k membership
Total participants, beginning-of-year2013-01-011,888
Total number of active participants reported on line 7a of the Form 55002013-01-011,958
Total of all active and inactive participants2013-01-011,958
2012: UNUM LIFE AND DISABILITY 2012 401k membership
Total participants, beginning-of-year2012-01-011,838
Total number of active participants reported on line 7a of the Form 55002012-01-011,888
Total of all active and inactive participants2012-01-011,888
2011: UNUM LIFE AND DISABILITY 2011 401k membership
Total participants, beginning-of-year2011-01-011,505
Total number of active participants reported on line 7a of the Form 55002011-01-011,838
Number of retired or separated participants receiving benefits2011-01-010
Number of other retired or separated participants entitled to future benefits2011-01-010
Total of all active and inactive participants2011-01-011,838
2010: UNUM LIFE AND DISABILITY 2010 401k membership
Total participants, beginning-of-year2010-01-011,505
Total of all active and inactive participants2010-01-010
2009: UNUM LIFE AND DISABILITY 2009 401k membership
Total participants, beginning-of-year2009-01-011,403
Total number of active participants reported on line 7a of the Form 55002009-01-011,505
Number of retired or separated participants receiving benefits2009-01-010
Number of other retired or separated participants entitled to future benefits2009-01-010
Total of all active and inactive participants2009-01-011,505

Form 5500 Responses for UNUM LIFE AND DISABILITY

2022: UNUM LIFE AND DISABILITY 2022 form 5500 responses
2022-01-01Type of plan entityMulitple employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: UNUM LIFE AND DISABILITY 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: UNUM LIFE AND DISABILITY 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: UNUM LIFE AND DISABILITY 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes
2018: UNUM LIFE AND DISABILITY 2018 form 5500 responses
2018-01-01Type of plan entitySingle employer plan
2018-01-01Plan funding arrangement – InsuranceYes
2018-01-01Plan benefit arrangement – InsuranceYes
2017: UNUM LIFE AND DISABILITY 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: UNUM LIFE AND DISABILITY 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Plan funding arrangement – InsuranceYes
2016-01-01Plan benefit arrangement – InsuranceYes
2015: UNUM LIFE AND DISABILITY 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes
2014: UNUM LIFE AND DISABILITY 2014 form 5500 responses
2014-01-01Type of plan entitySingle employer plan
2014-01-01Plan funding arrangement – InsuranceYes
2014-01-01Plan benefit arrangement – InsuranceYes
2013: UNUM LIFE AND DISABILITY 2013 form 5500 responses
2013-01-01Type of plan entitySingle employer plan
2013-01-01Plan funding arrangement – InsuranceYes
2013-01-01Plan benefit arrangement – InsuranceYes
2012: UNUM LIFE AND DISABILITY 2012 form 5500 responses
2012-01-01Type of plan entitySingle employer plan
2012-01-01Plan funding arrangement – InsuranceYes
2012-01-01Plan benefit arrangement – InsuranceYes
2011: UNUM LIFE AND DISABILITY 2011 form 5500 responses
2011-01-01Type of plan entitySingle employer plan
2011-01-01Plan funding arrangement – InsuranceYes
2011-01-01Plan benefit arrangement – InsuranceYes
2010: UNUM LIFE AND DISABILITY 2010 form 5500 responses
2010-01-01Type of plan entitySingle employer plan
2010-01-01Submission has been amendedYes
2010-01-01Plan funding arrangement – InsuranceYes
2010-01-01Plan benefit arrangement – InsuranceYes
2009: UNUM LIFE AND DISABILITY 2009 form 5500 responses
2009-01-01Type of plan entitySingle employer plan
2009-01-01Plan funding arrangement – InsuranceYes
2009-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number608513
Policy instance 1
Insurance contract or identification number608513
Number of Individuals Covered450
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $15,848
Total amount of fees paid to insurance companyUSD $2,294
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $183,514
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,848
Amount paid for insurance broker fees2294
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
REGENCE BLUECROSS BLUESHIELD OF OREGON (National Association of Insurance Commissioners NAIC id number: 54933 )
Policy contract number10048133
Policy instance 5
Insurance contract or identification number10048133
Number of Individuals Covered481
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $117,691
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $2,835,021
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $101,131
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number608515
Policy instance 4
Insurance contract or identification number608515
Number of Individuals Covered19
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $1,463
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,003
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,350
Additional information about fees paid to insurance brokerCOMMISSIONS PAID
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number608514
Policy instance 3
Insurance contract or identification number608514
Number of Individuals Covered125
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $5,716
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $35,173
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $5,276
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADD'L COMPENSATION
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number608513
Policy instance 2
Insurance contract or identification number608513
Number of Individuals Covered419
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $10,998
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $142,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,215
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number8009
Policy instance 1
Insurance contract or identification number8009
Number of Individuals Covered235
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $33,452
Welfare Benefit Premiums Paid to CarrierUSD $1,707,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $33,452
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number8009
Policy instance 1
Insurance contract or identification number8009
Number of Individuals Covered248
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $24,995
Welfare Benefit Premiums Paid to CarrierUSD $1,475,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $24,633
Insurance broker organization code?3
Additional information about fees paid to insurance brokerRETENTION BONUS
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number608513
Policy instance 2
Insurance contract or identification number608513
Number of Individuals Covered384
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $9,189
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $97,879
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $7,962
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract number1027433
Policy instance 3
Insurance contract or identification number1027433
Number of Individuals Covered572
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $150,441
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,229,795
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $150,441
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number608514
Policy instance 4
Insurance contract or identification number608514
Number of Individuals Covered98
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $3,564
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,290
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADD'L COMPENSATION
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number608515
Policy instance 5
Insurance contract or identification number608515
Number of Individuals Covered18
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $1,311
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $8,069
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,210
Additional information about fees paid to insurance brokerCOMMISSIONS PAID
Insurance broker organization code?3
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number8009
Policy instance 1
Insurance contract or identification number8009
Number of Individuals Covered285
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $31,589
Total amount of fees paid to insurance companyUSD $774
Welfare Benefit Premiums Paid to CarrierUSD $1,677,862
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,817
Amount paid for insurance broker fees774
Insurance broker organization code?3
Additional information about fees paid to insurance brokerRETENTION BONUS
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number608513
Policy instance 2
Insurance contract or identification number608513
Number of Individuals Covered433
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $11,022
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $126,637
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,442
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION PAID
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract number1027433
Policy instance 3
Insurance contract or identification number1027433
Number of Individuals Covered609
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $169,299
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,845,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $169,299
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number608514
Policy instance 4
Insurance contract or identification number608514
Number of Individuals Covered74
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $3,069
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $18,888
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,833
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADD'L COMPENSATION
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number608515
Policy instance 5
Insurance contract or identification number608515
Number of Individuals Covered19
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $1,516
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $9,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,399
Insurance broker organization code?3
Additional information about fees paid to insurance brokerADD'L COMPENSATION
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number608515
Policy instance 5
Insurance contract or identification number608515
Number of Individuals Covered27
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $1,792
Total amount of fees paid to insurance companyUSD $156
Temporary Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $11,943
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,792
Amount paid for insurance broker fees156
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number608214
Policy instance 4
Insurance contract or identification number608214
Number of Individuals Covered65
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $2,771
Total amount of fees paid to insurance companyUSD $246
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $17,562
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,771
Amount paid for insurance broker fees246
Additional information about fees paid to insurance brokerADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker name
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract number1027433
Policy instance 3
Insurance contract or identification number1027433
Number of Individuals Covered578
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $157,267
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,567,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $157,267
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON, LLC
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number000000608513
Policy instance 2
Insurance contract or identification number000000608513
Number of Individuals Covered99
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $8,992
Total amount of fees paid to insurance companyUSD $1,430
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $107,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,992
Amount paid for insurance broker fees1430
Additional information about fees paid to insurance brokerADDITONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON LLC
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number8009
Policy instance 1
Insurance contract or identification number8009
Number of Individuals Covered301
Insurance policy start date2017-01-01
Insurance policy end date2017-12-31
Total amount of commissions paid to insurance brokerUSD $30,563
Total amount of fees paid to insurance companyUSD $488
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,693,888
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,563
Amount paid for insurance broker fees488
Additional information about fees paid to insurance brokerRETENTION BONUS
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON, LLC
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number8009
Policy instance 1
Insurance contract or identification number8009
Number of Individuals Covered297
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $38,593
Total amount of fees paid to insurance companyUSD $1,129
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,807,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $38,593
Amount paid for insurance broker fees1129
Additional information about fees paid to insurance brokerRETENTION BONUS
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON, LLC
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberOR065507
Policy instance 2
Insurance contract or identification numberOR065507
Number of Individuals Covered408
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $20,471
Total amount of fees paid to insurance companyUSD $1,482
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $167,057
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $20,471
Amount paid for insurance broker fees1482
Additional information about fees paid to insurance brokerN/A ADDITIONAL COMPENSATION
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON, LLC
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract number1027433
Policy instance 3
Insurance contract or identification number1027433
Number of Individuals Covered1041
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of commissions paid to insurance brokerUSD $153,865
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,369,813
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $153,865
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON, LLC
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberOR065507
Policy instance 2
Insurance contract or identification numberOR065507
Number of Individuals Covered383
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $22,670
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $182,627
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $22,670
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON LLC
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number8009
Policy instance 1
Insurance contract or identification number8009
Number of Individuals Covered175
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $13,381
Total amount of fees paid to insurance companyUSD $293
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $767,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,381
Amount paid for insurance broker fees293
Additional information about fees paid to insurance brokerRETENTION BONUS
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract number1027433
Policy instance 3
Insurance contract or identification number1027433
Number of Individuals Covered1215
Insurance policy start date2014-01-01
Insurance policy end date2014-12-31
Total amount of commissions paid to insurance brokerUSD $179,209
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $4,570,729
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $179,209
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number8009
Policy instance 1
Insurance contract or identification number8009
Number of Individuals Covered175
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $13,381
Total amount of fees paid to insurance companyUSD $293
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $767,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $13,381
Amount paid for insurance broker fees293
Additional information about fees paid to insurance brokerRETENTION BONUS
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberOR065507
Policy instance 2
Insurance contract or identification numberOR065507
Number of Individuals Covered376
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $23,272
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $186,049
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,118
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON LLC
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract number1027433
Policy instance 3
Insurance contract or identification number1027433
Number of Individuals Covered1407
Insurance policy start date2013-01-01
Insurance policy end date2013-12-31
Total amount of commissions paid to insurance brokerUSD $285,341
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,123,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $285,341
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameBROWN & BROWN OF OREGON
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberOR065507
Policy instance 2
Insurance contract or identification numberOR065507
Number of Individuals Covered380
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $23,590
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $187,845
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $23,590
Additional information about fees paid to insurance brokerN/A
Insurance broker organization code?3
Insurance broker nameFULLERTON & COMPANY INC
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract number1027433
Policy instance 3
Insurance contract or identification number1027433
Number of Individuals Covered1376
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $283,918
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $7,189,682
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $283,918
Insurance broker organization code?3
Insurance broker nameFULLERTON AND COMPANY INC
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number8009
Policy instance 1
Insurance contract or identification number8009
Number of Individuals Covered132
Insurance policy start date2012-01-01
Insurance policy end date2012-12-31
Total amount of commissions paid to insurance brokerUSD $18,293
Total amount of fees paid to insurance companyUSD $662
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $886,415
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $18,293
Amount paid for insurance broker fees662
Additional information about fees paid to insurance brokerRETENTION BONUS
Insurance broker organization code?3
Insurance broker nameFULLERTON & COMPANY INC
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract number1027433
Policy instance 3
Insurance contract or identification number1027433
Number of Individuals Covered1351
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Welfare Benefit Premiums Paid to CarrierUSD $6,797,068
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberOR065507
Policy instance 2
Insurance contract or identification numberOR065507
Number of Individuals Covered344
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $20,345
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $163,630
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number8009
Policy instance 1
Insurance contract or identification number8009
Number of Individuals Covered143
Insurance policy start date2011-01-01
Insurance policy end date2011-12-31
Total amount of commissions paid to insurance brokerUSD $11,428
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
HEALTHNET (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number58511
Policy instance 1
Insurance contract or identification number58511
Number of Individuals Covered1150
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $53,506
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,784,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $53,506
Additional information about fees paid to insurance brokerNA
Insurance broker organization code?3
Insurance broker nameFULLERTON
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST (National Association of Insurance Commissioners NAIC id number: 95540 )
Policy contract number8009
Policy instance 2
Insurance contract or identification number8009
Number of Individuals Covered126
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $8,741
Total amount of fees paid to insurance companyUSD $17
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $489,202
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $8,741
Amount paid for insurance broker fees17
Additional information about fees paid to insurance brokerENTERTAINMENT
Insurance broker organization code?3
Insurance broker nameFULLERTON & COMPANY INC
LIFEMAP ASSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97985 )
Policy contract numberOR065507
Policy instance 3
Insurance contract or identification numberOR065507
Number of Individuals Covered285
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $15,351
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $124,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,351
Additional information about fees paid to insurance brokerNA
Insurance broker organization code?3
Insurance broker nameFULLERTON & COMPANY INC
PACIFICSOURCE HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 54976 )
Policy contract number1027433
Policy instance 4
Insurance contract or identification number1027433
Number of Individuals Covered1189
Insurance policy start date2010-01-01
Insurance policy end date2010-12-31
Total amount of commissions paid to insurance brokerUSD $127,414
Welfare Benefit Premiums Paid to CarrierUSD $4,097,485
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $127,414
Insurance broker nameFULLERTON AND COMPANY INC

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